Organization: The Lancet
Site of publication: thelancet.com
Type of publication: Article
Date of publication: March 15, 2022
Section 5: investing in the future of Nigeria— health for wealth
Prosperity, macroeconomics, and health
The total GDP of Nigeria was estimated at $448 billion in 2019. Five sectors are the major contributors to the per capita total health expenditure was $72·7 and the proportion of total health expenditure relative to GDP was 3·6% in 2018.
Moreover, most of this expenditure was private with public spending as a percentage of total health expenditure constituting only 16·3%, whereas private spending as a percentage of total health expenditure was 76·6% and out-of-pocket spending as a percentage of total health expenditure was 74·9%. External resources as a percentage of total health expenditure were 7·7%. Total health expenditure as a percentage of GDP has remained between 3·4% and 4·1% since 2006.
Nigeria hosted and signed the 2001 Abuja declaration, in which African governments committed to allocate at least 15% of government spending to health. The low levels of total health expenditure to GDP ratio and public spending on health, and the heavy burden of disease shows that it is important that overall health expenditure is increased. Without an increase in total health expenditure to GDP ratio, only an increase in GDP will lead to a rise in total health expenditure (from all sources, most currently being out-of-pocket). Nigeria should concurrently increase its GDP, the overall fiscal space, and the proportion of the budget allocated to health as outlined further on in this Commission.
Concerted advocacy and community engagement efforts from committed and powerful national and state-level institutions and civil society organisations could push health (including harm-reduction and pro-health multisectoral policies) and health-care funding up the political agenda, making it a key election issue. In subsequent elections, holding politicians to account at the ballot box for their previous promises to improve health and access to healthy environments, could engender sustained progress.
The COVID-19 pandemic and other health security risks could present the opportunity to increase this advocacy through political engagement. The investment case for health spending in Nigeria is clear, health spending provides value for money and can be politically rewarding.
The investment case
Value for money
Spending existing revenues in ways that efficiently and equitably decrease the burden of disease to in turn reduce health-care need is crucial, as is direct investment in multisectoral action to prevent disease (table 4) and better strategic purchasing in the health sector to improve diagnosis and treatment.
Rapidly increasing health expenditure, even by as little as $30 per capita per year (around $6 billion per year; table 5) could substantially improve coverage of essential health-care packages resulting in less sickness and death for millions. This increase in health expenditure in turn would improve wellbeing and economic output via increased individual, family, and community activity, and contribute to a rapid improvement in the nation’s wealth.
Delivering such an improvement in health and wealth would bring political dividends to national and state governments. The promise of this win-win-win situation therefore necessitates overcoming the barriers stopping it from happening.
Increasing health expenditure as outlined in table 5 only constitutes approximately 2·5 times the current $11·85 (16·3%) public spending of total health expenditure per capita of $72·7 in 2019. The true costs required, however, are likely to be much higher than these costs extrapolated from the National Health Strategic Development Plan 2.
For example, given experience with the COVID-19 pandemic, far more than $0·01 per capita per year is likely to be needed for adequate provision for the programme area of public health emergencies, preparedness, and response.
Similarly, for neglected tropical diseases to be addressed, far more than $0·06 per capita per year expenditure is required. Investment in health promotion and social determinants of health also needs increasing from $0·07 per capita per year to several dollars per capita at least, especially considering such funding would reap many times the amount in benefits. It is also important to note that total health expenditure per capita has been as high as $108 in 2014, even though health coverage and outcomes are poor, which is likely to be related to the high proportion derived from out-of- pocket expenditure.
Therefore, it would be prudent for the government to at least double annual health expenditure per capita to $168 or perhaps even triple it to $252, while dramatically increasing the proportion that is public expenditure (or pooled funding) and reducing out-of-pocket expenditure, as has been attempted in India and Ethiopia.
These increases would entail investments of ₦157 trillion to double annual health expenditure or ₦236 trillion to triple annual health expenditure for the whole of the 2021–30 period, or 10–15% of total GDP over the decade (2020 GDP for Nigeria was estimated at ₦152 trillion).
Nigerian Governments must recognize this as an investment in a prosperous nation rather than a cost. Given the size and importance of this investment, it must also be accompanied by measures that promote efficiency and effectiveness throughout the system, while prioritizing interventions that give the most value (ie, health) for money. To illustrate the value of efficient spending on health, show how investments in maternal, neonatal and child health can save millions of lives in Nigeria over the next decade. The estimated $10·5 per capita per year is slightly more than that estimated for maternal and reproductive health ($5–6) and child health ($1–3) combined from the NHSDP2 aggressive scale-up scenario.
This scale-up is a 63% increase in coverage, and a corresponding 63% increase in all cadres of health workers and health facilities could be needed to deliver this gain. Newly recruited health workers will require training, supportive supervision, and adequate salaries and benefits. New facilities will need to be planned, constructed, and maintained, with a key consideration being facility locations that reflect health needs. In an analysis of health facility data, we show a clear association between the quality of health facility infrastructure and childhood vaccination outcomes at state level.
Multisectoral action on the determinants of health will play a key role in any effort to improve health, including those related to diet, water and sanitation, air quality, transport, habitation, and the environment.
Targeted investments in the health sector that will improve financial and physical access to priority public health services and consequently improve health outcomes should markedly bolster the positive image that the citizenry have of the initiating level of government. Examples of past programmes that have paid off politically include the Saving One Million Lives initiative targeting maternal, newborn, and child health interventions, the NPHCDA Primary Healthcare Centre Revitalization strategy targeted at ensuring there is at least one PHC in every ward across the country to promote access, and the Primary Health Care Under One Roof strategy to integrate management of PHCs for more efficiency, as well as the now defunct
Subsidy Reinvestment and Empowerment Programme for Maternal and Child Health (SURE-P MCH) and National Health Insurance-Millennium Development Goals (NHIS-MDG) programmes. The branding of such special programmes is usually effective for galvanizing political support and ensuring that the beneficiaries are aware of the sources of the interventions.
Ensuring accountability and mitigating against corruption
Corruption has been defined as the abuse of entrusted power, such that a person, group, or organization acquires undue benefits. These benefits might be financial, material, or non-material. Health systems are especially susceptible, often with life-threatening consequences. Yet, corruption in the health sector is often seen as intractable.
Health sector corruption impedes access to health
care, therefore, effective solutions are needed to tackle them. Universal health coverage should mean action on determinants of health and health-care provision. The Nigerian Government and commercial and industrial interests therefore need to be held accountable for ensuring Nigeria is a healthy country to live and grow in. Nigeria cannot achieve universal health coverage if the system is corrupt. The most common types of corruption in the Nigerian health system, which has to be eliminated for the country to make reasonable progress in achieving its health goals are absenteeism, procurement-related corruption, under-the-counter payments, health financing-related corruption, and employment-related corruption.
Experience from other settings shows that although the health sector plays a crucial role in advocating for this approach, there is need for a cross-sectoral mechanism to facilitate and coordinate measures to address corruption (eg, the office of the governor or mayor or equivalent).
There is also a need to explicitly address accountability, value for money, and corruption in the Nigerian health sector. Institutional mechanisms to govern procurement, prevent informal payment, and discourage absenteeism also need to be set-up and managed with high-level oversight and accountability.
To improve accountability, transparency, and efficiency, and reduce corruption, it will be important to strengthen public financial management systems within the health sector at the federal, state, and local government levels. This process will involve governments ensuring that expenditure tracking mechanisms are instituted and routinely applied at all levels of government for both government and donor spending, and the Ministries of Finance promptly transferring funds to institutions within the health sector against approved plans. There should be capacity building of managers at national and subnational levels on budget negotiation and management.
Funding the health system
Funding sources and their shortcomings
Nigeria continues to spend very little on health and health care compared with its peers in the region and around the world. As of 2018, the share of government spending assigned to health care was only 5·2%, slightly above the average of 3·4% between 1981 and 2018.
The share of government spending has been as low as 0·2% (1992) with the highest share of spending in 2011 at about 7% (appendix p 33). Compared with the rest of Africa, Nigeria’s Government spending on health care is only 0·5% of GDP, lower than the African regional average of 2% and the world average of 3·5% as of 2017.
Government spending in total health expenditure across four major categories (government spending, out-of-pocket spending, external development assistance, and prepaid private spending) is both lower and more volatile in Nigeria compared with other countries in the sub-Saharan Africa region.
The health system can become a positive reflection of Nigeria—with successful health reform the catalyst to show why Nigeria matters to Nigerians, giving good reason for patriotism, and serving as a model for wider societal change
The share of government spending in total health expenditure was 26% on average between 1995 and 2014, lower than the sub-Saharan Africa average of 37%. Out-of-pocket spending is a much higher share of health expenditure in Nigeria than in sub-Saharan Africa (appendix p 34). There is a strong negative correlation between the share of government spending in total health expenditures and the share of out-of- pocket spending in total health spending in Nigeria at –0·92 (p<0·001), presenting a contrast with the sub- Saharan Africa region where there is no significant correlation between the two. In Nigeria, the share of out-of-pocket spending on health was 67% on average between 1995 and 2014, reaching 70% in 2014, which is much higher than the average of 31% in sub-Saharan Africa over the same period. Nigerians are forced to rely on out-of-pocket expenditure when government spending on health falls, imposing a substantial economic cost in a country where 40% of the population, nearly 83 million people, live below the poverty line of $382 per year according to the 2019 National Bureau of Statistics estimates.
The National Strategic Health Development Plan 2 (2018–2022) set a target of reducing out-of-pocket expenditure to 35% of overall health expenditure, however the latest available data from 2019 show that out-of-pocket expenditure has not reduced and still accounts for over three-quarters (78%) of all health expenditure.
Indeed, out-of-pocket expenditure has not been below 70% since 2005. The vast majority of the burden of financing health care therefore is on the people of Nigeria, presenting a serious barrier to care- seeking, entrenching inequality, and inducing catastrophic health expenditure and medically-induced poverty for many Nigerians every year. The World Bank estimates that 50% of Nigerians were at risk of catastrophic health expenditure for surgical care in 2020, with the percentage varying from 38% to 54% between 2007 and 2020. Studies in Enugu and Anambra states have shown rates of 15% of actual catastrophic health expenditure in 2008 and 27% in 2010, with catastrophic spending measured at a threshold of 40% of non-food expenditure.
In the past two decades, external development assistance has grown in importance, constituting 7% as a share of total health spending in 2014. Countries that effectively utilise donor funding generally have stronger health systems, governance, and financing. However, the performance of donor funding in Nigeria has been limited by weak government coordination of donor activities, with sustainability also adversely affected by the failure of some state governments to pay counterpart funds, lateness in payment, and the problem of donor fatigue.
The final major category for health financing is prepaid health spending, largely consisting of spending on private health insurance. Prepaid health spending has remained extremely low over time, averaging 3% of total health expenditure between 1995 and 2014, compared with 21% for sub-Saharan Africa over the same period. Although there were slight increases in the share of private health insurance in total health expenditure between 1995 and 2002, the share has fallen and is low, falling to near its lowest point at 0·8% in 2014 (compared with 21% for sub-Saharan Africa in 2014).
Section 6: conclusions and recommendations
With Nigeria’s large and growing population, ongoing governance and security challenges, and potential leadership role in Africa and globally, the decisions made today will determine whether Africa’s most populous country will become a success story or a cautionary tale. A successful Nigeria will inarguably require strong investments in health, education, and basic public services, following a central organizing principle of creating a healthy population (ie, a health- in-all-policies approach). Such an approach is the best pathway to human flourishing, economic development, and a legacy for the politicians who achieve it.
The strength of institutions—in government, civil society, traditional and religious authorities, and within communities—can and must be harnessed to engender and reap the benefits of a virtuous cycle of prosperity and good health. Institutions, including formal structures such as the constitution and laws, and informal societal factors such as customary norms and values, are requisite to achieving the political and social accountability that continues to elude the nation.
The alternative of business-as-usual risks a spiral of increasing poverty, inequality, and insecurity as the growing population is blighted by the interdependent challenges of lack of opportunity, poor education, and poor health. Delivering a health agenda for Nigeria is thus a matter of the utmost importance for Nigeria, the subregion, and the world.
In this Commission, we began by exploring how Nigeria’s health system, writ large, evolved from a widely accessible community health infrastructure during the pre-colonial period, to an inegalitarian colonial inheritance, ultimately leading to a post- independence period of an unequally distributed, unbalanced, and weak health system despite multiple national plans over six decades.
Nevertheless, the story of the Nigerian health system presents numerous successes that can serve as lessons to build upon. The overall progress over the past 50 years shows that most indicators have moved in the right direction, although there is much room for improvement. Further, Nigeria effectively utilized vertical programmes with inter- national multilateral agency support to contain Guinea worm disease and wild-type poliomyelitis showing that the health system can, in particular circumstances, deliver. There is a distinct opportunity to fulfil Nigeria’s constitutional promise to ensure health care to all persons and extend this to wider preventive health goals.
The giant of Africa—Africa’s largest country in terms of population and economy—enjoys considerable unrealized potential. The time to achieve greatness is now, with health at the heart of the development agenda. The health system can become a positive reflection of Nigeria—with successful health reform the catalyst to show why Nigeria matters to Nigerians, giving good reason for patriotism, and serving as a model for wider societal change.